Search

In this phase 2 multicenter study, we evaluated the incorporation of autologous stem cell transplantation (ASCT) into a carfilzomib-lenalidomide-dexamethasone (KRd) regimen for patients with newly diagnosed multiple myeloma (NDMM). Transplant-eligible patients with NDMM received 4 cycles of KRd induction, ASCT, 4 cycles of KRd consolidation, and 10 cycles of KRd maintenance. The primary end point was rate of stringent complete response (sCR) after 8 cycles of KRd with a predefined threshold of ≥50% to support further study. Seventy-six patients were enrolled with a median age of 59 years (range, 40-76 years), and 35.5% had high-risk cytogenetics. The primary end point was met, with an sCR rate of 60% after 8 cycles. Depth of response improved over time. On intent-to-treat (ITT), the sCR rate reached 76%. The rate of minimal residual disease (MRD) negativity using modified ITT was 70% according to next-generation sequencing (

Introduction: The combination of carfilzomib, lenalidomide, and dexamethasone (KRd), with and without autologous stem cell transplantation (ASCT) is an effective regimen for newly diagnosed multiple myeloma (NDMM) (Jakubowiak et al., Blood 2012 and Jasielec et al., Blood 2020). The addition of daratumumab to KRd (Dara-KRd) for 8 cycles led to a measurable residual disease (MRD)-negativity rate of 71% (flow cytometry, limit of detection [LoD] Methods: This is an open-label, single arm, Multiple Myeloma Research Consortium phase 2 study enrolling pts with NDMM, regardless of transplant eligibility. Subjects requiring urgent therapy may receive 1 cycle of therapy (Rd and/or Bortezomib) prior to enrollment. Pts receive Dara-KRd for 24 cycles: daratumumab 16 mg/kg IV Days 1, 8, 15, 22 for cycles 1 & 2, days 1 and 15 for cycles 3-8, then day 1 for cycles 9-24; carfilzomib 20/36 mg/m2 on days 1,2,8,9,15,16 for cycles 1-8, then 36 mg/m2 on days 1, 2, 15, 16 for cycles 9-24; lenalidomide 25 mg PO days 1-21 of a 28 day cycle for 24 cycles; dexamethasone 40 mg PO weekly (20 mg if age > 75) for cycles 1-9, and 20 mg PO weekly for cycles 9-24. ASCT-eligible pts had the option to harvest stem cells to permit ASCT in the future if desired. All subjects undergo testing for MRD using NGS (clonoSEQ, Adaptive Biotechnologies) with a lower LoD of < 10 -6 at the end of cycles 8 (C8) and 24 (C24). The primary endpoint is the rate of stringent CR and/or MRD-negativity (sensitivity threshold 50% with Dara-KRd (85% power using a one-sided alpha=0.10). Results: Of the 29 pts who have been enrolled from March 2019- July 2021, 18 (62%) are evaluable at the C8 timepoint and of which 7/18 are evaluable at C24 by intention-to-treat analysis. The remaining 11 pts are on therapy but have not yet reached C8. 19 pts have an identifiable clone to enable MRD testing by NGS (one sequencing failure, one not performed, eight tests pending). Median age is 57 years (range 42-79; 5 pts >70 years of age). Eight (28%) pts identify their race as Black and 5 (17%) as Hispanic ethnicity. High-risk cytogenetics (per IMWG criteria) is present in 16/29 (55%). 18 pts (62%) have undergone stem cell collection; median stem cell yield is 8.06x10 6 CD34+/kg. For the 18 pts evaluable for the primary endpoint at C8, the overall response rate is 94% (13 sCR, 4 VGPR, 1 PD) (Figure 1). There are 13 MRD-evaluable pts at C8; the sCR and/or MRD-negativity rate ( Responses deepened over time; 4/9 (56%) pts converted from MRD-positive at C8 to MRD-negative (10 -6 threshold) at either C12 or C24. One patient withdrew from the study after C12 to pursue ASCT (VGPR at time of withdrawal). One patient had primary refractory disease after one cycle of therapy and subsequently died from disease progression and CNS involvement. Grade 3+ leukopenia and thrombocytopenia occurred in 21% and 24%, respectively; notable grade 3+ nonhematologic adverse events were hypertension (14%) and a single case of thrombotic microangiopathy leading to discontinuation of carfilzomib. There were no other grade 3 cardiovascular toxicities. Conclusions: The combination of Dara-KRd as extended frontline therapy for NDMM without employing ASCT can induce high rates of MRD-negativity within 8 cycles, exceeding the historical sCR rate of KRd without Dara. Importantly, the rate and depth of MRD-negativity improve beyond cycle 8, suggesting that extended Dara-KRd without ASCT may generate rates of sCR and MRD-negativity comparable to KRd with ASCT. Yearly longitudinal determinations of MRD after completion of 24 cycles of Dara-KRD protocol treatment will generate information on the durability of MRD and the role of ASCT compared to shorter treatments with Dara-KRd, with and without ASCT. Figure 1 Figure 1. Disclosures Derman: Sanofi: Membership on an entity's Board of Directors or advisory committees. Rosenblatt: Wolters Kluwer Health: Consultancy, Patents & Royalties; Attivare Therapeutics: Consultancy; Parexel: Consultancy; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Imaging Endpoints: Consultancy; Bristol-Myers Squibb: Research Funding. Avigan: Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmacyclics: Research Funding; Kite Pharma: Consultancy, Research Funding; Juno: Membership on an entity's Board of Directors or advisory committees; Partner Tx: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Aviv MedTech Ltd: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Legend Biotech: Membership on an entity's Board of Directors or advisory committees; Chugai: Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy; Parexcel: Consultancy; Takeda: Consultancy; Sanofi: Consultancy. Jakubowiak: Janssen: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Gracell: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees.

8011 Background: The addition of a monoclonal antibody to triplet induction regimens in patients (pts) with MM with intent for autologous stem cell transplant (ASCT) has resulted in higher overall and deep response rates. In this study we are investigating the impact of the addition of Elo to KRd on complete response (CR) and/or MRD-negative rates in newly diagnosed MM regardless of transplant eligibility. Methods: Pts were enrolled from four MM Research Consortium sites into this phase 2 study. All patients receive 12 cycles of Elo-KRd in 28-day cycles: Elo per standard dosing, K 20/56/70 mg/m2 days 1, 8 and 15, R 25 mg days 1-21, and dexamethasone 40 mg days 1, 8, 15, 22. ASCT eligible candidates can undergo stem cell collection after cycle 4 and then resume treatment; pts who elect to proceed to ASCT are censored for response at that time. Pts MRD(-) (-5) by NGS after cycles 8 (C8) and 12 (C12) proceed to Elo-Rd until progression. Patients who convert from MRD(+) to MRD(-) between C8 and C12 receive an additional 6 cycles of Elo-KRd (total 18 cycles) followed by Elo-Rd, and pts MRD(+) after C12 receive an additional 12 cycles of Elo-KRd (total 24) followed by Elo-Rd. The primary endpoint of the study is sCR and/or MRD(-) rate after C8 E-KRd. MRD status was determined by ClonoSEQ next generation sequencing (NGS, -5) [Adaptive Biotechnologies]. An improvement in the sCR and/or MRD(-) rate by NGS from a historical 30% to 50% at the end of C8 will be considered promising. Results: 44 pts are enrolled, 39 of whom are evaluable for response (cutoff Jan 10 2021). Median age is 62 years (range 43-81, 23% age >70) and 23 (52%) have high-risk cytogenetic abnormalities (HRCA) including 13 (30%) with >2 high-risk abnormalities (6 pts unknown cytogenetics). 34/39 (87%) have MRD trackable by clonoSEQ. The rate of sCR and/or MRD(-) by NGS at the end of C8 is 19/33 (58%), meeting the statistical threshold for establishing efficacy (2 pts censored for elective ASCT before C8 and 4 pts receiving therapy but have not reached C8). With a median follow-up of 24 months, estimated 2-year progression free survival is 87% (100% for standard risk, 79% for HRCA) and estimated 2-year overall survival is 89% (82% for HRCA). No pt who was MRD(-) by NGS after C8 has progressed, including 6 pts with HRCA. Serious adverse events occurred in 30 pts (68%). 89% experienced treatment emergent AEs, the most common (>10%) of which was pneumonia (14%). One pt had grade 5 myocardial infarction. Conclusions: Elo-KRd demonstrates tolerability consistent with known toxicities of these agents and met the primary endpoint of sCR and/or MRD(-) of >50% after 8 cycles. With longer follow-up, the study results may validate that an MRD-adaptive design for de-escalation of therapy in MM can generate deep responses while reducing treatment exposure. Clinical trial information: NCT02969837.

Introduction: Lenalidomide (LEN) is a cornerstone in the treatment of newly diagnosed MM both as part of induction and maintenance therapy. As a result, most patients at first or second relapse are LEN exposed/refractory creating a need for effective 2nd line and salvage therapies. While no standard of care regimen has been established in early relapse, several therapies have been evaluated combining second generation immunomodulatory agents, proteasome inhibitors, and daratumumab. We have previously reported the results from the phase I/II trial of KPd demonstrating excellent efficacy in a LEN-refractory patient population. Here, we present the first efficacy and safety results from the cohort in which DARA was added to KPd (D-KPd). Methods: This is a multi-center, open-label, Phase 1b/2 study in subjects with relapsed MM with two sequential treatment cohorts: KPd and D-KPd. Eligibility criteria and KPd doses and schedules were identical for both cohorts. Subjects with measurable disease that progressed after at least 1 prior therapy (LEN refractory disease was required for 2nd-line therapy and LEN refractory/exposed for ≥ 3rd line) were eligible. The KPd cohort has completed enrollment (n=67) and results have been previously reported. The D-KPd cohort received treatment on the following 28-day schedule: Pomalidomide 4 mg daily on days 1-21 for cycles 1-8+, Carfilzomib 20/27 mg/m2 on days 1,2,8,9,15,16 for C1-8, then 1,2,15,16 for C9+ (maintenance), dexamethasone 20 mg days 1,2,8,9,15,16,22,23 for C1-2, then 40 mg days 1,8,15,22 for C3+. DARA was administered as per standard schedule, weekly for the first 2 cycles, then every 2 weeks for cycles 3-6, and monthly thereafter. A Minimax two-stage design was employed for enrollment of subjects on this cohort. Twenty-one patients were required to accrue to the first stage, with at least 4 responders of ≥nCR at 4 cycles necessary to accrue to second stage for a total of 34 pts. Primary endpoint was rate of nCR/CR as per IMWG criteria. Minimal residual disease (MRD) was evaluated by 10-color flow cytometry with limit of detection (LOD) 10-4-10-5 and will also be assessed by next-generation sequencing (LOD 10-5-10-6). Secondary endpoints include overall response rate, depth of response, progression-free survival (PFS), and overall survival. Per study design, a nCR/CR rate of >35% (over the historical 20% rate) would support further study of the D-KPd regimen. Results: As of July 29, 2020, all 22 subjects who were enrolled into the D-KPd cohort were evaluable for safety and the primary endpoint. Median age was 62 (range 37-74) with a median of 1 (range 1-3) prior lines of therapy. 81% of patients were LEN refractory, and high-risk cytogenetics per IMWG criteria were present in 12/19 (68%) evaluable patients. Subjects completed a median of 12.5 cycles (range 2-33) of therapy and 21 (95%) subjects completed at least 4 cycles; 1 subject progressed after cycle 2. In the ITT population (n=22), after 4 cycles, 86% achieved ≥PR and 46% ≥nCR, warranting further enrollment to a second stage. At best response, the ≥PR was 86% with 55% ≥nCR/CR, 45% ≥sCR, and 55% MRD negativity by flow cytometry (n=22). The most common grade 3-4 hematologic adverse events included neutropenia (64%), lymphopenia (36%), and febrile neutropenia (18%). The most common grade 3-4 non-hematologic adverse events included fatigue (27%), respiratory infections (23%), diarrhea (14%), and insomnia (14%). There was one thrombotic event (4.5%) which was grade 2. In comparison to the KPd cohort (67 patients with similar baseline characteristics), there was an improvement in efficacy as demonstrated by an increase in rate of ≥nCR at the end of 4 cycles (from 7% to 46%), as well as the best response (from 20% to 55%). High risk cytogenetics did not significantly affect response (≥nCR 46% at best response [all sCR]). With 20 months of follow-up, median PFS was not reached in the D-KPd cohort and 12-month PFS is 84% vs 63% for KPd. Rates of grade 3/4 cytopenias were higher in the D-KPd cohort. There was no treatment related mortality and 19 of 22 pts are alive. Conclusion: D-KPd demonstrates high efficacy in a population of patients with relapsed/refractory multiple myeloma enriched for high risk cytogenetics. MRD negativity by flow cytometry was achieved in 55% of subjects. The ≥nCR rate of 55% with D-KPd compares favorably to the 20% rate with KPd alone; based on the study design, this warrants further evaluation of D-KPd. Disclosures Zonder: BMS, Celgene: Research Funding; Intellia, Amgen, Takeda, Janssen, Regeneron, Alnylam, Caelum, Oncopeptides: Consultancy. Reece:Janssen, Bristol-Myers Squibb, Amgen, Takeda: Consultancy, Honoraria; Janssen, Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Merck: Honoraria, Research Funding; Otsuka: Research Funding. Berdeja:Kesios: Research Funding; Karyopharm: Consultancy; Acetylon: Research Funding; Vivolux: Research Funding; Abbvie: Research Funding; Amgen: Consultancy, Research Funding; Bioclinica: Consultancy; BMS: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Cellularity: Research Funding; Constellation: Research Funding; CURIS: Research Funding; EMD Sorono: Research Funding; Genentech, Inc.: Research Funding; Glenmark: Research Funding; Janssen: Consultancy, Research Funding; Kite Pharma: Consultancy; Legend: Consultancy; Lilly: Research Funding; Novartis: Research Funding; Poseida: Research Funding; Takeda: Consultancy, Research Funding; Teva: Research Funding; Prothena: Consultancy; Servier: Consultancy; Bluebird: Research Funding; CRISPR Therapeutics: Consultancy, Research Funding. Jakubowiak:Adaptive, Juno: Consultancy, Honoraria; AbbVie, Amgen, BMS/Celgene, GSK, Janssen, Karyopharm: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

e14030 Background: Improvements in cancer treatment, supportive care, and the approval of oral chemotherapy medications over the past decade have resulted in an increasing number of cancer patients treated in outpatient settings. Transitioning cancer treatments to the outpatient setting places greater emphasis on proper medication counseling and optimal side effect management. Current literature demonstrates improvements in medication adherence and effective cancer related symptom management with the addition of an oncology pharmacist. Historically, the University of Chicago Medical Center (UCMC) has not employed pharmacists into their ambulatory oncology clinics. UCMC is evaluating pharmacist’s roles in these clinics. Methods: The primary objective of this project is to evaluate the clinical and financial impacts of an oncology clinical pharmacist specialist in an interdisciplinary multiple myeloma (MM) clinic. This will be evaluated by monitoring the interventions made by the pharmacist in clinic through a validated scoring tool. This tool associates a value for each type of intervention made based on current literature and internal evaluations at UCMC. The oncology clinical pharmacist specialist will be available for consult by the MM clinic staff. The pharmacist may be consulted for any medication related inquiry. Based on the consult the pharmacist will categorize their interventions into twelve predefined intervention categories. Results: Study results showed the implementation of a clinical pharmacist specialist into the MM clinic over 39 clinic days resulted in 241 patient consults and 474 interventions made by the pharmacist. The most frequent interventions made by the pharmacist were medication teaching (97), dose adjustments by pharmacist (82) and medication reconciliation (63). Based on the dollar values associated with each intervention type, the value of interventions made by the pharmacist during the study period was $189,441 with a predicted annual value of $757,764. Conclusions: An clinical pharmacist specialist in the MM clinic lead to dramatic and sustainable financial and clinical impacts. Further investigation into other oncology clinics is warranted.

Checkpoint kinase 1 (ChK1) plays a key role in the DNA damage response, facilitating cell-cycle arrest to provide sufficient time for lesion repair. This leads to the hypothesis that inhibition of ChK1 might enhance the effectiveness of DNA-damaging therapies in the treatment of cancer. Lead compound 1 (GNE-783), the prototype of the 1,7-diazacarbazole class of ChK1 inhibitors, was found to be a highly potent inhibitor of acetylcholine esterase (AChE) and unsuitable for development. A campaign of analogue synthesis established SAR delineating ChK1 and AChE activities and allowing identification of new leads with improved profiles. In silico docking using a model of AChE permitted rationalization of the observed SAR. Compounds 19 (GNE-900) and 30 (GNE-145) were identified as selective, orally bioavailable ChK1 inhibitors offering excellent in vitro potency with significantly reduced AChE activity. In combination with gemcitabine, these compounds demonstrate an in vivo pharmacodynamic effect and are efficacious in a mouse p53 mutant xenograft model.

The master regulators of the eukaryotic cell cycle are cyclin-dependent protein kinases (CDKs), a highly conserved but functionally diverse enzyme family that also has essential roles in transcription, neuronal physiology, differentiation and apoptosis. CDK-containing complexes drive cell-cycle events and, as the targets of checkpoint pathways, integrate signals to ensure appropriate cell-cycle progression. X-ray crystallography has provided a detailed understanding of the mechanisms by which CDK activity is regulated. Recently reported structures have provided insights into how the protein assemblies that mediate the specific degradation of CDK regulatory proteins function and how checkpoint pathways integrate with the cell cycle.

The human trefoil proteins TFF1 and TFF3 are expressed predominantly in the gastrointestinal tract. They are also expressed and regulated by estrogens in malignant breast epithelial cells. TFF1 and TFF3 are small cysteine-rich acidic secreted proteins of 60 and 59 amino acids with similar isoelectric points of 4.75 and 3.94, respectively. Each contains one trefoil domain that is characterized by several conserved features including six cysteine residues with conserved spacing. TFF1 and TFF3 form intermolecular disulfide bonds via an extra-trefoil domain cysteine residue and are present in vivo as monomers and homodimers and as complexes with other proteins. The TFF1 dimer is more active than the TFF1 monomer. In the present study the hydrodynamic and charge properties of TFF1 and TFF3 monomers and homodimers have been compared and shown to differ markedly. Notably, TFF1 is significantly more asymmetric than TFF3 (frictional coefficients 1.25 and 1.12, respectively, p < 0.001), and homodimerization of TFF1 results in a greater increase in asymmetry than for TFF3. The overall charges of TFF1 and TFF3 are very different at neutral pH. Titration curves predicted significant differences in charge across a wide pH range that agreed well with experimental data. The locations of charged amino acids in the primary sequences and in the tertiary structures of TFF1 and TFF3 were examined. This revealed interesting divergence in both the distribution and local topology of charged amino acid side chains. The significant differences between the shape, size, and surface charge of these two closely related molecules may account for their divergent biological activities.

The authors examined 219 referrals to a forensic psychology outpatient service between 1989 and 1996. Factors including age of client, whether it was first or subsequent referral, number of agencies previously involved, and type of problem were examined to determine their relationship to the outcomes of nonattendance, early dropout, or completion of assessment/therapy. Type of problem for which the referral was made was found to be significant, with referrals for anger control carrying a poor prognosis for successful completion of therapy. Recommendations for the more effective functioning of the service were made.

Route Designer, version 1.0, is a new retrosynthetic analysis package that generates complete synthetic routes for target molecules starting from readily available starting materials. Rules describing retrosynthetic transformations are automatically generated from reaction databases, which ensure that the rules can be easily updated to reflect the latest reaction literature. These rules are used to carry out an exhaustive retrosynthetic analysis of the target molecule, in which heuristics are used to mitigate the combinatorial explosion. Proposed routes are prioritized by an empirical rating algorithm to present a diverse profile of the most promising solutions. The program runs on a server with a web-based user interface. An overview of the system is presented together with examples that illustrate Route Designer’s utility.

The K homology module, one of the most common RNA-binding motifs, is present in multiple copies in both prokaryotic and eukaryotic regulatory proteins. Increasing evidence suggests that self-aggregation of KH modules has a functional role. We have used a combination of techniques to characterize the behavior in solution of the third KH domain of Nova-1, a paradigmatic KH protein. The possibility of working on the isolated module allowed us to observe specifically the homodimerization and RNA-binding properties of KH domains. We provide conclusive evidence that self-association of Nova-1 KH3 occurs in solution even in the absence of RNA. Homodimerization involves a specific protein/protein interface. We also studied the dynamical behavior of Nova-1 KH3 in isolation and in complex with RNA. These data provide a model for the mechanism of KH/RNA recognition and suggest functional implications of dimerization in KH complexes. We discuss our findings in the context of the whole KH family and suggest a generalized mode of interaction.

N-utilizing proteins (Nus) form a complex involved in the regulation of rRNA biosynthesis in enteric bacteria by modulating the efficiency of transcriptional termination [Nodwell, J. R., and Greenblatt, J. (1993) Cell 72, 261-268]. The protein NusE (identical to the protein S10 of the small ribosomal subunit) from the pathogenic mycobacterium M. tuberculosis has been cloned and overexpressed in Escherichia coli. The pure protein has been characterized by circular dichroism, ultracentrifugation, NMR, and binding to NusB. The near-ultraviolet circular dichroism spectrum of this protein suggests that it has a moderate (ca. 12-16%) alpha-helical content at 30 degrees C. The protein undergoes cold denaturation, with a temperature of maximum stability near 40 degrees C, implying a substantial heat capacity difference between the folded and unfolded states. The sedimentation equilibrium and velocity data indicate that the protein is monomeric and expanded in solution. NMR spectroscopy shows that there is no significant tertiary structure, and confirms the low secondary structure content at low temperatures. Furthermore, there was evidence for more structure at 30 degrees C than at 10 degrees C. Well-defined shifts in peaks in the HSQC spectrum of (15)N labeled NusE/NusB when the unlabeled counterpart was added at approximately stoichiometric concentrations showed the formation of a NusE-NusB complex in the absence of RNA. The far-UV CD and ultracentrifuge experiments, however, indicated relatively weak binding. Isothermal titration calorimetry showed the binding was weak and endothermic at 15 degrees C, with a total DeltaH ofor =10 kcal/mol. This weak binding is consistent with a small interaction interface and lack of large conformational rearrangements in the predominantly unfolded NusE protein. The conformational flexibility of NusE may be important for its roles in both the ribosome and antitermination complexes.

Both prokaryotes and eukaryotes regulate transcription through mechanisms that suppress termination signals. An antitermination mechanism was first characterized in bacteriophage lambda. Bacteria have analogous machinery that regulates ribosomal RNA transcription and employs host factors, called the N-utilizing (where N stands for the phage lambda N protein) substances (Nus), NusA, NusB, NusE and NusG. Here we report the crystal structure of NusB from Mycobacterium tuberculosis, the bacterium that causes tuberculosis in humans. This molecule shares a similar tertiary structure with the related Escherichia coli protein but adopts a different quaternary organization. We show that, unlike the E. coli homolog, M. tuberculosis NusB is dimeric both in solution and in the crystal. These data help provide a framework for understanding the structural and biological function of NusB in the prokaryotic transcriptional antitermination complex.